Behavioral Health Integration Research Articles

Integration of Behavioral and Oral Health in Health Centers

Integration of Behavioral and Oral Health in Health Centers

Behavioral Health Integration and Age-Friendly Systems

Behavioral Health Integration and Age-Friendly Systems

"Integrated behavioral health plus": The best of the worlds of collaborative care management, primary care behavioral health, and primary care.

Discussions comparing the components and virtues of models of integrated behavioral health (IBH), that is, collaborative care management and primary care behavioral health, have been ongoing. In this conceptual article, we recommend shifting the focus to a broader set of components we have found essential to serve the needs of our patients, and hopefully the broader aims of dissemination and implementation of IBH. We detail our 20-year experience including the personnel, program components, challenges, successes, and plans for the future that will meet our patients' behavioral health needs and serve primary care. We compare our "IBH Plus" approach using the central tenets of primary care known as the "six Cs" (6Cs) to two dominant models, illustrating differences and similarities among them. The "6Cs" are first contact/accessibility, continuity, comprehensiveness, coordination, context-based, and accountability. We detail how each of these "6Cs" guides the structure and functioning of IBH Plus in the team-based patient-centered medical home setting. We believe IBH Plus more clearly relates to and supports the rest of the primary care transformation movement while integrating components of the most popular models of IBH and may support greater implementation of IBH. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Non-communicable diseases and the prospects of integrated behavioral health in India: current status and future directions

PurposeContextual to the recognition of the complex interplay between health and behavioral aspects, integrated behavioral health (IBH) has emerged. Although this model is becoming popular in the Western world, its presence in the global context is not promising. This paper aims to explore the need for IBH in India and address its barriers to implementation and possible solutions.Design/methodology/approachWe analyzed the case of IBH and its potential implications for India using the current evidence base, authors' reflections and experience of implementing similar programs.FindingsThis paper identifies contextual factors, including increased instances of non-communicable diseases and psychosocial and cultural determinants of health, that necessitate the implementation of IBH programs in India. The key features of different IBH models and their applicability are outlined. The current status of IBH and potential challenges in implementation in India in terms of human resources and other factors are delineated. We also discuss the potential models for implementing IBH in India.Originality/valueIntegrating behavioral health in primary care is considered an effective and sustainable model to promote health and well-being across various target populations. Towards this end, this paper is the first to discuss the contextual factors of IBH in India. It is a significant addition to the knowledge base on IBH and its possible implementation barriers and strategies in low- and middle-income countries.

Integrating Behavioral Health and Primary Care

Osteopathic family physicians embody the philosophy of whole-person care, including using a biopsychosocial approach to incorporate mental health into patient care. The creation of the Behavioral Health Integration Collaborative increased support for a system-level adoption of whole-person care in primary care settings. With the increase in both mental health symptoms and diagnoses among Americans, and the increasing support for integrated physical and behavioral healthcare in the primary care setting, this paper shares various approaches, as well as challenges to, adapting integrated care in the primary care office. This includes reviewing best practices for implementing this care approach. The two leading models for integrated care are the Primary Care Behavioral Health (PCBH) model and Collaborative Care model (CoCM). Both models include clinically embedding licensed mental health professionals into the primary care setting, thus increasing access to colleagues with this specialized approach. The PCBH model utilizes a warm hand-off approach, resulting in a collaboration between physician and mental health provider in the care of the patient. The CoCM focuses on a registry of patients who are overseen by a behavioral health manager with treatment decisions guided by a consulting psychiatrist. Blended models are also emerging to better suit the needs for different practices and the patient populations they serve. Challenges to full implementation include acquiring buy-in from practice leadership, hiring appropriately trained mental health providers, and defining billing and coding procedures.

Current Practices in Clinical Supervision in Primary Care.

The purpose of this study was to examine current clinical supervision practices within primary care settings. We used a descriptive survey design, which blends quantitative and qualitative data, and examined the current state of clinical supervision practices and approaches in primary care and the type of training the behavioral health consultants received to provide supervision to pre-licensure level behavioral health trainees. Ninety-four participants completed the survey in 2022. Seventy-one percent of respondents felt they had adequate training to be an effective integrated behavioral health (IBH) supervisor; however, most training came from sources, such as workshops, continuing education, or supervision of supervision. Further efforts to establish universal competencies and formal training programs are needed to meet the growing need for IBH services in primary care.

Hospital Capabilities Associated With Behavioral Health Integration Within Emergency Departments.

To identify hospital capabilities associated with behavioral health (BH) processes in emergency departments (EDs). Six hundred two hospital responses to the 2017/2018 National Survey of Healthcare Organizations and Systems were linked to 2017 American Hospital Association Annual Survey data. Separate multivariable regressions estimated how hospital capabilities (the use of quality improvement methods, approaches to disseminate best patient-care practices, barriers to using care delivery innovations, and inpatient beds for psychiatric or substance use) were associated with each of 4 ED-based BH processes: mental health and substance use disorder screening, team-based approaches to BH, telepsychiatry, and direct referrals to community-based BH clinicians. Models controlled for hospital structural characteristics and area-level socioeconomic factors. Most hospitals screened for BH conditions and provided direct referrals to community-based BH clinicians. Approximately half of the hospitals used a team approach to BH. A minority had implemented telepsychiatry. Each additional process used to disseminate best patient-care practices was associated with more screening for BH conditions (an increase of 4.07 points on the screening index, P <0.01) and greater likelihood of using a team approach to BH [4.41 percentage point ( P <0.01) increase]. Hospitals reporting more barriers to the use of care delivery innovations reported less screening and use of a team approach [a decrease of 0.15 points on the screening index ( P <0.01) and 0.28 percentage points reduction in likelihood of team approach use ( P <0.001) for 1-point increase in the barrier index]. Research and interventions focused on removing innovation barriers or adding processes to disseminate best practices offer a path to accelerate BH integration in hospital EDs.

Access, Utilization, and Quality of Behavioral Health Integration in Medicaid Managed Care

Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change. To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health. This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023. Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures. This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care. The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.

Using a Behavioral Health Integration Model in a Family Nurse Practitioner Residency.

Primary care serves as an entry point for many patients to access health care services, especially those who reside in medically underserved areas. Because an initiative exists for family nurse practitioners (FNPs) to fill primary care gaps in medically underserved areas, they must be included in educational strategies to provide quality behavioral health care within their scope of practice. An academic-practice partnership was used to provide FNP residents the opportunity to learn to work within their scope of practice in a behavioral health integration model. The residents noted satisfaction with the learning environment, supervisory relationship, and role of the faculty. Innovative continuing education activities are needed to prepare novice FNPs to safely practice and enter into a health care workforce pipeline focused on reducing disparities in medically underserved areas. [J Contin Educ Nurs. 2024;55(4):203-208.].

Behavioral Health Integration on Inpatient Obstetric Units: Program Development, Strategies for Implementation, and Lessons Learned.

Perinatal mood and anxiety disorders and substance use disorders are the primary causes of maternal mortality in the postpartum period and represent major public health concerns. Despite this, these conditions remain undertreated. Behavioral health integration in outpatient obstetric settings is necessary but insufficient to meet the needs of all patients. Inpatient behavioral health integration represents a promising avenue for addressing gaps in care. Results from recent program development indicate that needs assessment, stakeholder backing, collaboration with existing programs, and adaptability are key factors in successful implementation.

Expanding Access to Cognitive Behavioral Therapy: A Purposeful and Effective Model for Integration

Integrated behavioral health (IBH) in primary care is growing as an approach to decrease barriers and provide earlier intervention for youth experiencing behavioral and mental health symptoms. However, increasing access to mental health providers alone without ensuring evidence-based treatment (EBT) is provided will not sufficiently address the current mental health crisis. To spread to scale, IBH needs to be implemented and tested in community-based practices with integrity to EBT. This paper provides a model for implementing cognitive behavioral therapy (CBT) in community pediatric primary care via master’s prepared therapists through an academic-community partnership. This paper describes the hiring practices, training in CBT, ongoing supervision and consultation, and use of data to inform the evolution of the model. Using a retrospective review of the rate of emergency department (ED) admissions per 1,000 patients with a diagnosis of depression, we compared practices enrolled in our academic-community partnership IBH model to practices who implemented their own IBH and practices with no IBH. Across a four-year period, we found that practices enrolled in the academic-community partnership IBH model had a lower number of patients per 1,000 patients with a diagnosis of depression admitted to the ED with behavioral health concerns compared to practices that did not incorporate an IBH therapist. There was no difference in ED admission rates per 1,000 between practices that hired their own IBH and those without IBH. Analysis of costs of the program against generated revenue from billed services demonstrated that the academic-community partnership model shows promise of sustainability.

Examining the use of psychiatric collaborative care and behavioral health integration codes at federally qualified health centers: A mixed-methods study.

Despite evidence to support the integration of behavioral health and physical health care, the adoption of Integrated Behavioral Health (IBH) has been stymied by a lack of reliable and sustainable financing mechanisms. This study aimed to provide information on the use of Psychiatric Collaborative Care Model (CoCM) and behavioral health integration (BHI) codes and the implementation of IBH in federally qualified health centers (FQHCs). This cross-sectional, mixed-methods study involved an electronic survey of administrators and follow-up qualitative interviews from a subset of survey respondents. Quantitative data were analyzed using descriptive analysis and thematic coding was used to analyze qualitative data to identify salient themes. Administrators (N = 52) from 11 states completed the survey. Use of CoCM (13%) or BHI codes (17.4%) was low. Most administrators were not aware that CoCM (72%) or BHI codes (70%) existed. Qualitative interviews (n = 9) described barriers that further complicate IBH and code use like workforce shortages and insufficient reimbursement for the cost to deliver CoCM services. Although FQHCs are working to meet the needs of the communities they serve, a lack of billing clarity and awareness and workforce issues hinder the adoption of the CoCM. FQHCs face many demands to provide care to safety net populations, yet are not fully equipped with the resources, workflows, staffing, and payment structures to support CoCM/BHI billing. Increased financial and logistical support to build practice infrastructure is needed to reduce the administrative complexity and inadequate reimbursement mechanisms that currently hinder the implementation of the CoCM and integrated care delivery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

H.O.P.E. grows: An academic-public health partnership to reimagine public health services and increase mental health access among socially vulnerable populations.

To illustrate the process of developing and sustaining an academic-public health partnership for behavioral health integration through an expansion of the Aligning Systems for Health (ASfH) framework. Practice-informed primary data (2017-2023) from the Holistic Opportunity Program for Everyone (HOPE) Initiative based in Charlotte, NC. The unit of analysis in this descriptive case study is inter-organizational, specifically focusing on an academic-public health relationship. We illustrate the partnership process across the ASfH four core areas, including key challenges and insights. Utilized a Critical Moments Reflection methodology and review of HOPE program data. (1) Formal partnership structures and processes are essential to monitoring the four ASfH core components for on-going system alignment. (2) Aligning systems for health principally involves two ecologies: (i) the health program and (ii) the partnership. The vitality and sustainability of both ecologies require continuous attention and resource investment. (3) Relationships rest at the heart of aligning systems. (4) With comparative advantages in research methods, the academic sector is especially poised to collaborate with healthcare systems and human service organizations to study, develop, implement, and scale evidence-based health interventions. The academic sector shares overlapping purposes with the public health, healthcare, and social services sectors while providing complementary value. It is a critical sectoral partner in advancing population health and health equity.

“Death by a Thousand Cuts”: Agriculture Producer Resiliency in the Western United States

ABSTRACT Objective Agricultural producers face a wide array of stress triggers, shocks, and long-term pressures such as drought, flooding, fire, government policies, financial insecurity, and physical injuries. Extant research has revealed that mental health stigma, lack of access to care in rural areas, and negative coping responses (alcohol abuse, suicide, prescription drugs use) exacerbate the challenge of producer responses to short and long-term adversity. Resilience, the traits, processes, and capacities of producers to adapt and transform their approach to farming or ranching, when necessary, in response to stress triggers or long-term pressures, has received less research attention, particularly in the Western United States. The purpose of the study was to apply an interactionist occupational resilience theoretical perspective to the investigation of contextual factors contributing to resilience in Western United States agricultural producers. Methods Qualitative interviews (45 to 90 minutes) were conducted with agricultural producers (n=51) from Western states and territories. Applied thematic analysis with a phenomenological lens was utilized to analyze interview transcriptions. First and second level coding were conducted to derive themes. Results The analysis revealed that resilience is based upon the interactions between traits of producers and the context of agriculture. Four themes were generated (Agricultural Life, External Stressors, Traits and Adaptations, and Supports and Resources), supported by subthemes. The themes and subthemes are depicted in an agricultural producer resiliency model. The findings shed light on the equivocal role of neighbors in providing support for each other and the double-edged sword of co-working with family. Conclusions The findings underscore that social capital is an important mechanism for supporting farmers and ranchers, as those with stronger social resources are more resilient. We recommend more funding to tailor stress and mental health programming to the specifics of agriculture, integration of behavioral health in primary care as a mechanism to increase access to care, and more intentional technical assistance for farmers and ranchers on strategic planning and problem solving.

Integrated Behavioral Health Adaptations During the COVID-19 Pandemic.

COVID-19 pandemic lockdowns threatened standard components of integrated behavioral health (IBH) such as in-person communication across care teams, screening, and assessment. Restrictions also exacerbated pre-existing challenges to behavioral health (BH) access. Semistructured interviews were completed with clinicians from family medicine residency programs on the impact of the pandemic on IBH care delivery along with adaptations employed by care teams to ameliorate disruption. Participants (n = 41) from 14 family medicine residency programs described the rapid shift to virtual care, creating challenges for IBH delivery and increased demand for BH services. With patients and care team members at home, virtual warm handoffs and increased attention to communication were necessary. Screening and measurement were more difficult, and referrals to appropriate services were challenging due to higher demand. Tele-BH facilitated continued access to BH services but was associated with logistic challenges. Participants described adaptations to stay connected with patients and care teams and discussed the need to increase capacity for both in-person and virtual care. Most practices modified their workflows to use tele-BH as COVID-19 cases increased. Participants shared key learnings for successful implementation of tele-BH that could be applied in future health care crises. Practices adapted readily to challenges posed by pandemic restrictions and their ability to sustain key elements of IBH during the COVID-19 pandemic demonstrates innovation in maintaining access when in-person care is not possible, informing strategies applicable to other scenarios.

A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions.

Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Considerations for Behavioral Health Integration Program Implementation in Pediatric Primary Care Settings: A Qualitative Study

BackgroundMore than 16% of children in the United States have a behavioral health (BH) disorder, but less than half receive recommended care. Integrated BH programs in primary care settings can address gaps in BH care. This qualitative study sought to understand pediatric primary care clinicians’ experiences with the novel multicomponent Behavioral Health Integration Program (BHIP) in a large network of independent pediatric practices and to identify potential barriers and facilitators for implementation of such programs. MethodsSemistructured interviews were conducted virtually with a purposive sample of clinicians in BHIP practices from November 2021 to April 2022. The Consolidated Framework for Implementation Research was the study’s theoretical framework. Interviews were audio-recorded and professionally transcribed. Transcripts were analyzed inductively and deductively using Charmaz’s constructivist grounded theory approach. ResultsOf the 31 participants, 74% identified as female and 97% as white. Most participants felt that BH care should be integrated into pediatric primary care and that BHIP helped to do so. Most barriers and facilitators identified centered on inner and outer setting Consolidated Framework for Implementation Research domains, including BH care delivery and finance; practice structures (staffing, training, scope of services, and management); practice culture (leadership, communication, and teamwork); and effects of integration on clinicians. ConclusionsBHIP provided important support for BH integration across varied settings. Potential considerations for effective implementation in other settings included expanded training for BH clinicians, tailoring integration to organizational and practice-level contexts, and increased advocacy to address the structural factors limiting of BH care delivery.

Mental Health Care Access Among Arab Immigrants in the United States: Application of Public Arena Model

Arab immigrants constitute a sizable portion of the US population, and their adjustment and relocation challenges might escalate mental health issues. Nevertheless, mental health care accessibility among such populations is not recognized as policy issue. Hence, it is crucial to explore the political tools that might be employed to improve immigrants’ access to mental health treatment. The Public Arenas Model (Hilgartner and Bosk, American Journal of Sociology 94:53–78, 1988) provides better understanding of how access to mental health care is defined in the public sphere, why mental health inaccessibility among Arabs has not received attention, and how stakeholders worked to raise the public’s attention to such issue (Smith, Policy, Politics & Nursing Practice 10:134–142, 2009). Ultimately, several policy options are proposed to address Arab immigrants’ access to mental health care issue, including increasing mental health service providers’ language proficiency and cultural competency, integration of behavioral health and primary care services for immigrant populations, and considering novel modes of mental health delivery.

Client perspectives on primary care integration in a rural-serving behavioral health center

PurposeAdvancing behavioral health and primary care integration is a priority for helping clients overcome the complex health challenges impacting healthcare deserts like those in Arizona, United States of America (USA). This study aimed to explore the perspectives of people with a substance use disorder (SUD) on accessing integrated primary care (IPC) services in a rural-serving behavioral healthcare organization in Arizona.Design/methodology/approachClients from a behavioral health facility in Arizona (n = 10) diagnosed with SUDs who also accessed IPC participated in a 45-min semi-structured interview.FindingsThe authors identified six overarching themes: (1) importance of IPC for clients being treated for SUDs, (2) client low level of awareness of IPC availability at the facility, (3) strategies to increase awareness of IPC availability at the behavioral health facility, (4) cultural practices providers should consider in care integration, (5) attitudes and perceptions about the experience of accessing IPC and (6) challenges to attending IPC appointments. The authors also identified subthemes for most of the main themes.Originality/valueThis is the first study in rural Arizona to identify valuable insights into the experiences of people with SUDs accessing IPC, providing a foundation for future research in the region on care integration.

Integrated Behavioral Health in Primary Care Residency and Nonresidency Practices.

Integrated behavioral health (BH) is becoming a preferred model of care for primary care because it improves patient outcomes and satisfaction. Little is known about whether residency practices are consistently modeling this preferred care model relative to real-world nonresidency practices. The study compared levels of BH integration, patient health outcomes, and satisfaction with care between residency practices and nonresidency practices with colocated BH providers. Baseline data were collected in 2018-2019 from 44 practices and their adult patients with chronic conditions participating in a cluster-randomized, pragmatic trial to improve BH integration. The sample included 18 (40.9%) residency and 26 (59.1%) nonresidency practices, with 1,817 (45.3%) patients from residency practices and 2,190 (54.7%) patients from nonresidency practices. Outcomes including BH integration levels (the Practice Integration Profile), patient health outcomes (the PROMIS-29), and patient satisfaction with care (the Consultation and Relational Empathy scale) were compared between residency and nonresidency practices using multivariate regression analyses. No differences were found between BH integration levels, patient health outcomes, and patient satisfaction with care between residency and nonresidency practices. In a sample of primary care practices with colocated BH providers, residencies had BH integration and patient outcomes similar to real-world practices. Primary care practices with residency programs reported comparable levels of BH integration, patient health outcomes, and patient satisfaction compared to practices without residency programs. Both types of practices require interventions and resources to help them overcome challenges associated with dissemination of high levels of BH integration.